Provider Demographics
NPI:1497129878
Name:BOOTHE, AUDREY (MSE)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:
Last Name:BOOTHE
Suffix:
Gender:F
Credentials:MSE
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSE
Mailing Address - Street 1:1384 E 105TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4606
Mailing Address - Country:US
Mailing Address - Phone:718-795-7002
Mailing Address - Fax:
Practice Address - Street 1:1384 E 105TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-4606
Practice Address - Country:US
Practice Address - Phone:718-795-7002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-22
Last Update Date:2015-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist